Difficult Patient vs Difficult Doctor
The following is a brief analysis of the dynamics associated with such behavior and hopefully toward resolution as researched and written by a first year medical student. The obvious goal, hopefully, is resolution of potential conflicts to promote a therapeutically effective doctor-patient relationship. My visitors' views on this issue are welcome. ...Maurice.
DIFFICULT PATIENT VS DIFFICULT DOCTOR
Surabhi Reddy
First Year Medical Student
A doctor’s worst nightmare? A patient that is impatient,
inattentive, rude, and demanding. A patient’s worst nightmare? A doctor that is
impatient, inattentive, rude, and demanding. A so-called “difficult patient” or
“difficult doctor” represent two sides of the same coin, with similar
behavioral and communicative factors causing conflict. Occasionally, the
difficult relationship may culminate in a
messy outburst – as recently seen in
a violent
altercation between a Gainesville doctor and patient.1 The duality of the patient-physician
relationship allows us to examine (from both perspectives) what underlying
actions and issues initiate the conflict – and eventually focus on mediation
and resolution. Addressing the “difficult” nature of these parties is a vital
first step towards creating positive patient-physician relationships and health
outcomes.
You may hear the phrase “difficult patient” offhandedly
thrown around in a physician’s lounge – a blanket term like “problem child” or
“one of those” that draws universal
understanding but little clarity on the specifics of the interaction.
Physicians characterize 15-20% of all patients as “difficult.”2,3 Such
encounters point to a strong association between the “difficult”
characterization and patient mental disorder – namely, depression, panic
disorder, and anxiety.2,3 Doctors note these patients are either 1)
not interested in a medical opinion whatsoever, or 2) have repetitive,
non-specific complaints. However, it was also noted that difficult
patients are hard to describe and characterize as a group.4 Mental
health does not preclude a difficult interaction. In a series of interviews,
physicians described “difficult” as conversational issues such as patients being “violent, demanding, aggressive, rude and [seeking]
secondary gain.”5 Physicians describe their primary motivations as
the desire to solve medical problems and help others – and anything that
stymies this process sadly draws the label “difficult.”
The onus is not completely on the patient, however. One
study points out that the difficulty may stem from the doctor’s work style, belief
system, and/or cultural barriers.5 The more experienced a family
medicine physician is, the less likely he/she is to characterize a patient as “difficult”
– suggesting that there is a burden on the doctor to develop the interpersonal
skills to handle the interaction. Collectively, physicians that report high
frustration with patients are those that are younger, work longer hours, and
have symptoms of depression, anxiety, and stress.6 While physicians
often characterize patients as difficult, patients are less likely to describe
their physician as so. In most studies, patients are evaluated for their
“satisfaction,” which includes many aspects of their medical care, including
perceived expectations, the underlying medical condition, and other members of
the healthcare team. This may also reflect the power dynamic between patient
and physician. Patient complaints may be dismissed, once again, as the patient
being “difficult” - leaving the physician immune to criticism.
The difficult patient-physician relationship involves both
behavioral (mental disorders, stress) and communicative (rude and aggressive
language) factors from both parties. Ultimately, cooperative relationships stem
from respect, empathy, and patience. As one physician stated in his interview,
“First of all, what I have learned with the years is being empathetic toward [patients].”
Taking the time to understand another’s perspective can go a long way in making
the difficult into easy.5
Sources
1.
Bever, Lindsey. (2017). A doctor shouted at a
sick mother to 'get the hell out.' Now he's under criminal investigation.
Washington Post.
2.
Hahn, S. R., Kroenke, K., Spitzer, R. L., Brody,
D., Williams, J. B., Linzer, M., & Verloin deGruy, F. (1996). The difficult
patient. Journal of general internal medicine, 11(1), 1-8.
3.
Jackson, J. L., & Kroenke, K. (1999).
Difficult patient encounters in the ambulatory clinic: clinical predictors and
outcomes. Archives of Internal Medicine, 159(10), 1069-1075.
4.
Koekkoek, B., van Meijel, B., &
Hutschemaekers, G. (2006). " Difficult patients" in mental health
care: a review. Psychiatric Services, 57(6), 795-802.
5.
Steinmetz, D., & Tabenkin, H. (2001). The
‘difficult patient' as perceived by family physicians. Family practice, 18(5),
495-500.
6.
Krebs, E. E., Garrett, J. M., & Konrad, T.
R. (2006). The difficult doctor? Characteristics of physicians who report
frustration with patients: an analysis of survey data. BMC health services
research, 6(1), 128.
posted by Maurice Bernstein, M.D. @ 4:39:00 PM
45 comments
45 Comments:
For those visitors who want more discussion on "Difficult Patient", I found that I and my visitor PT among others wrote views on "Difficult Patient: What is your definition and ARE YOU ONE" back in June 2012:
http://bioethicsdiscussion.blogspot.com/2012/06/difficult-patient-what-is-your.html
However, you may still want to write comments here specifically with regard with what the medical student wrote. ..Maurice.
As a patient I try to follow physician instructions completely. I agree to whatever tests or procedures they indicate are needed, and I defer to his/her medical expertise. I suppose that would make me a good patient but I at times cross the line into bad patient territory by advocating for myself on matters that have no medical significance but which bump against "the way we do things here". Sedation makes me ill so I refuse it for simple procedures like colonoscopies. It only takes one person to examine my genitals in a full skin exam and so I expect the scribe and nurse to excuse themselves for it. These things make me a bad patient with physicians that adhere to a one size fits all approach to patient management.
My examples can also be used to define bad physicians. The physician who won't believe me when I say "done it before, not a big deal" when I'm saying no sedation is a bad physician that I fire. I know what I tolerate well. He doesn't. The physician who cannot accept that as a male I am uncomfortable with a female scribe and nurse observing my genital exam and insists on me having an audience is choosing to not see me as a person. Another bad physician. A good physician at least makes an attempt to listen to what the patient is trying to tell them and speaks to the issue that's been raised.
A good physician allows patients to ask questions. Once I asked my physician about being called with the results of follow-up testing that was done after initial surgery for cancer. He snapped at me that if he had to call every patient with their test results he wouldn't get anything done, that he'll let me know when there's something he thinks I need to know. After that I was afraid to ask him any questions at all. Patients aren't afraid of good doctors.
Fortunately whereas some doctors might label me a bad patient, there are good doctors out there who don't because for them the minor items I advocate for myself on are just that, minor items that don't really interfere with them being the doctor and me being the patient.
I can tell this was written by a medical "professional." The first response to the alleged difficult patient is mental illness. Medicine assumes that if you do not blindly follow a doctor's orders, then there must me something (mentally) wrong with you. For this reason, we had to enact POLSTs, DNRs, and living wills.
Both Ray and myself have demonstrated that medical school causes mental trauma (illness). Remember the whole physician suicide issue?
Yet, business as usual, it is always the patients' fault. The Krebs, Garrett, & Konrad fails to label doctors as mentally ill, but instead says "have symptoms of depression, anxiety, and stress..."
Again, the medical professional claims the patients ARE mentally ill saying "Such encounters point to a strong association between the “difficult” characterization and patient mental disorder – namely, depression, panic disorder, and anxiety" and of course it is supported by the Hahn, Kroenke, Spitzer, Brody, Williams, Linzer, & Verloin deGruy AND Jackson, & Kroenke studies.
If Surabhi Reddy and the referenced articles attribute patient-physician difficulties to mental illness, then the majority of fault lies with physicians. The 2017 Medscape article "Physician Suicide," states "In every population, suicide is almost invariably the result of untreated or inadequately treated depression or other mental illness..."
It goes on to say "Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and up to 19.5% of females. Depression is even more common in medical students and residents, with 15-30% of them screening positive for depressive symptoms...
However, because of the stigma associated with depression in almost all cultures, which seems to be greatly magnified among medical practitioners, self reporting likely underestimates the prevalence of the disease in medical populations. .."
-- Banterings
Here is my nightmare list of difficult patients
Visiting the emergency room for a refill
Emergency room physician to patient " Who is your primary care physician? Patient says Well Doctor you are. ER physician says no I'm not your family physician."
Diabetic inpatient ordering pizza and has it delivered to the patients room at the hospital why? Patient says the hospital food doesn't taste good.
Female patient presenting to the emergency room saying she is deathly ill, but, apparent she has spent the last 3 hours applying makeup and jewelry.
Homeless patients who complain that the hospital was negligent in losing his wallet with $5,000 in it.
I could go on and on and on!
PT
Banterings, I am aware that the author of the document reproduced here is a first year medical student who like all first year medical students are not yet full and complete "medical professionals" but are just beginning "to get their feet wet" into that final designation. It is just the beginning of "learning medicine" and "learning the criteria of being and maintaining a state of professionalism" which combined hopefully will provide a needed benefit to the human society they will be offering their knowledge and skills. ..Maurice.
Maurice,
I am aware of that too. Unfortunately, the criticisms that I made of the written piece can be applied to well seasoned professionals. My point was demonstrated in my criticism of the articles LABELLING the patients as mentally ill while the physician article only says EXHIBIT SYMPTOMS.
Somewhere along the way, the hidden curriculum has infected this student (already) with the concept that patients who disagree with their physician must be mentally ill, yet the student is (dare I say) still uncorrupted enough to entertain the prospect that the physician may suffer from mental illness. I am sure that if this was written by a 3rd year student it would be titled "What To Do With the Difficult Patient."
So then why would a first year student worry about such a topic unless the hidden curriculum has already infected this student?
Anthropologically, because doctors have embraced the paternalistic model of medicine, social systems have pushed to a patient centered model. Society kept its "social contract" (Paul Starr ) with medicine by NOT telling physicians HOW to treat, but society requires physicians to have malpractice insurance (or go to jail or retire in poverty), lawsuits have driven bad physicians not to be able to afford the higher rates (being a higher risk), and thus become employees subject to satisfaction surveys and corporate customer service policies.
-- Banterings
Banterings, with regard to the "hidden curriculum", that curriculum extending from the 3rd and 4th years of medical school and beyond is unlike the curriculum we provide first and second year students which is "open" in the sense that it is provided by a known set of instructors with a open and uniform set of topics and viewpoints. They are not developed "on the spur of the moment" and may vary with the instincts and modus operandi of the "instructor" which underlies the "hidden curriculum".
Nevertheless and this is the basis for this thread, I and other instructors admit there is always a possibility of "fault" on both sides of the doctor's desk and the potential for such a possibility is an essential element to be taught as part of the education regarding medical professionalism. And yes, with regard to the "finger pointing" of the graphic for this thread, it would be wrong to say that only one hand with one finger was expressing the "truth" of the relationship.
..Maurice.
Banterings,
Thank you for your comments and critique. As Dr. Bernstein mentioned, I am just getting my feet wet in the grand scheme of medical education, so most of my writing is derived from literature research rather than my own experiences or insight.
The idea of a "difficult" patient or physician presents a challenging research topic, however (as it is a qualitative and abstract characterization). While some researchers utilize interviews to detail what exactly makes the interaction difficult, another approach is to see what medical conditions correlate with the "difficult" label in patient. The highlighted papers report that mental illnesses like general anxiety disorder and persistent depressive disorder are the common correlates - so that is why I chose to include the discussion of mental health. However, as you mention, this can lead to a dangerous mindset in which doctors automatically label a difficult/disagreeing patient as mentally ill (reflective of a greater problem in physicians). I felt appropriate to include "However, it was also noted that difficult patients are hard to describe and characterize as a group. Mental health does not preclude a difficult interaction...This may also reflect the power dynamic between patient and physician. Patient complaints may be dismissed, once again, as the patient being “difficult” - leaving the physician immune to criticism.
I also appreciate your commentary on the mental health of physicians themselves - which as you mention, is prone to illness. I believe there is has been a strong push (in our medical school, atleast), for future doctors to prioritize their own mental health and wellbeing to question how "fit" they are to perform their duties and to empower their treatment.
Lastly, I agree with the notion that doctors are "employees subject to satisfaction surveys and corporate customer service policies."
-Surabhi
Maurice,
...a possibility of "fault" on both sides of the doctor's desk...
Forgive my cynicism, this sounds like a reluctant admission to the obvious, that there IS fault on both sides.
As to the hidden curriculum, are your 1st and 2nd year students NOT around older physicians and 3rd and 4th year students? Have you ever read any threads on the Student Doctor Network web site?
The Student Doctor Network bills itself as a nonprofit educational organization founded in 1999 for prehealth and health professional students in the United States and Canada.Source:
Spoiler Alert: According to the Student Doctor Network, it IS ALWAYS the patient's fault.
1st and 2nd year students have plenty of opportunity to be exposed to the hidden curriculum. How often are the anecdotes in class (especially the "On Doctoring" course) about the difficult patient and how often are they about the difficult physician?
The problem with paternalism is that it assumes the physician is always right. We even see the remnants in the patient rights and responsibilities. Of course the patient has the right to participate in decision making, BUT...
The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician's orders. Source:
Some progressive institutions say the patient is responsible to follow the agreed upon plan.
If you look at the Graphic of this thread, there is one finger pointing at the other, but 3 fingers pointing back at the person...
-- Banterings
Banterings, I disagree with the conclusion that breaks in the patient-doctor relationship is "always the patient's fault".
The doctor-patient relationship can be looked upon as two cars approaching each other in two directions or going in the same direction but in a narrow alleyway. In each analogy, it requires attention to each other and attention to the goal of safe passage. It is never a one-sided issue. Continuing with this analogy, it is the duty of medical school teachers and those educators who follow to promote safe and effective passage of both vehicles in either direction.
With regard to when the "hidden curriculum" begins to infiltrate first or second year students mindset by communication with their colleagues in the third and fourth years or others, we must ask someone like first year student Surabhi. I know that first and second year students are NOT taught that physician paternalism is still the dominant accepted behavior and that there is only "difficult" behavior on the patient's side of the doctor's office table. ..Maurice.
Surabhi,
Thank you for responding to me. I wish you success and that you end up being one of the good physicians.
You should be aware of the natural human instinct of "Fight or Flight." In deed, it is recognized in English Common Law and is the basis f our self defense laws here in the US. That being said, in cases where patients perceive the situation as their life hangs in the balance of the encounter, then the hard wired instinct of fight or flight kicks in.
Due with the logistical problems of trying to find a new doctor (flight), then the fight instinct will kick in. Is someone fighting for their life or quality of life really a difficult person? Then there is the issue of noncompliant ( a slur against patients) and non-adherent. I remember a study that found that patients that were labeled noncompliant had underlying issues and NOT mental illness or just being difficult.
Of patients that were not taking medication, the issue was that the patients could not afford the cost of the medications prescribed. The paper encouraged physicians to see if this was the issue and seek cheaper alternatives for the plan of care. (Source: Working with the Noncompliant Patient)
Here is a meme that illustrates how providers can retaliate and become difficult themselves: This has been around for a long time and I have seen nurses commonly share this on social media. I have also heard from physicians that they have retaliated against patients with painful or embarrassing procedures.
One such that is common in inner city EDs is having a suspected opioid seeker undergo a painful test. The thinking is that the drug seeker will forego any tests that may diagnose and properly treat the supposed pain, but the person really in pain will endure anything to chase a cure. I am sure that PT and NTT can back me on these assertions.
The one reference that you cite says that older GPs (as opposed to younger, less experienced, heavy workloads, residents, and students) are less likely to label patients as difficult. That begs the question, are med schools sending out physicians that are not properly equipped to deal with patients?
Even the mental health community is sounding the alarm that mental illness is over diagnosed.
-- Banterings
Maurice,
No offense, but how do you know?
By your very own admission you do not know how your students end up despite you teaching them correctly.
Have you ever read articles on SDN or KMD?
Here is a good article: AFP Managing Difficult Encounters: Understanding Physician, Patient, and Situational Factors.
This is a relatively new way of thinking. Looking back on articles dealing with difficult patients, most of them do NOT list one of the potential causes as difficult physicians. Most list as patient mental illness.
-- Banterings
To the question of whether 1st yr students are corrupted by the "hidden curriculum":
I can say from my experience that we have little contact with 3-4yr student and attending physicians (and more so with designated clinical instructors like Dr. Bernstein). Our curriculum does, in fact, emphasize that a "difficult" patient should not be labelled as so without self-examination and consideration of external factors (like noncompliance due to being unable to afford medication - as Banterings points out). Our "Difficult Patient" workshop was actually re-named to "The Difficult Patient-Physician Relationship" for this reason.
However, I cannot speak for 3rd-4th year students or students that do a lot of physician shadowing or clinical work, as they may be exposed to the bias that is mentioned in labeling patients as mentally-ill.
To the point that older GPs are less likely to label patients as "difficult": I do not think this is an indication that younger/stressed physicians are ill-prepared. Effective communication and collaboration with patients is a highly nuanced issue - and experienced physicians are better at navigating these issues. Many situations cannot be simulated in medical school, and the learning must be conducted in an experiential manner. I think it actually paints a hopeful picture for the progress physicians can make through their career.
Also would like to point out that while Student Doctor Network is a large forum for medical students and hopefuls, I don't think it represents the average medical student or resident. I find reddit.com/medicalschool to better represent conversations I may have with someone in my medical school class.
Surabhi,
Please do not use the term noncompliance, as it is a slur against patients.
Thank you for the Reddit reference.
As to the self examination, then what do you do if the physician finds one's self being difficult; put "difficult physician" in the patient's records? Forgive my cynicism, but this is the type of things that patients are routinely subjected to.
I would love it if you "stop back" from time to time in the future and let us know what you experience in your education.
-- Banterings
"You cannot offend me, but you are welcome to try."
Banterings, I agree with the related editorial linked to the last reference you gave.
Family physicians commonly find themselves in difficult clinical encounters. These encounters often leave the physician feeling frustrated. The patient may also be dissatisfied with these encounters because of unmet needs, unfulfilled expectations, and unresolved medical issues. Difficult encounters may be attributable to factors associated with the physician, patient, situation, or a combination. Common physician factors include negative bias toward specific health conditions, poor communication skills, and situational stressors. Patient factors may include personality disorders, multiple and poorly defined symptoms, nonadherence to medical advice, and self-destructive behaviors. Situational factors include time pressures during visits, patient and staff conflicts, or complex social issues. To better manage difficult clinical encounters, the physician needs to identify all contributing factors, starting with his or her personal frame of reference for the situation. During the encounter, the physician should use empathetic listening skills and a nonjudgmental, caring attitude; evaluate the challenging patient for underlying psychological and medical disorders and previous or current physical or mental abuse; set boundaries; and use patient-centered communication to reach a mutually agreed upon plan. The timing and duration of visits, as well as expected conduct, may need to be specifically negotiated. Understanding and managing the factors contributing to a difficult encounter will lead to a more effective and satisfactory experience for the physician and the patient.
My opinion is that perhaps most "difficult patients" would not be considered "difficult" if physicians had the time and took the time to "diagnose" the current damaged relationship itself. Unfortunately, because of time limitations and self-denial, many physicians may miss the opportunity and instead of diagnosing "difficult", acting to heal the relationship as the doctor is intending to heal the physical pathology, this important relationship disorder may be ignored. Diagnosing "Mental illness" as the problem may be an excuse for the physician
ignoring a "bilateral working together deficiency". If this deficiency is noted and understood by the physician, "difficult patient" may become an unnecessary description. What do you think? ..Maurice.
To My Visitors: What does the Nassar conviction and sentencing now tell us about the medical profession and behavior. Should every patient in the future consider the medical profession a source of potholes of evil intent and behavior which should be actively avoided? If not, then what? ..Maurice.
Maurice,
As to Nassar (and all the other providers who have betray the trust of their patients), a physician can no longer expect the blind trust of patients, especially since the fiduciary duty of physicians is NOT law. Instead, they should expect patients to allow the physician to earn the trust of the patients.
Furthermore, Nassar believes that he did nothing wrong. Look at his statement he made at his sentencing:
"It's just a short statement.
Your words these past several days -- their words, your words -- have had a significant emotional effect on myself and has shaken me to my core.
I also recognize that what I am feeling pales in comparison to the pain, trauma, and emotional destruction that all of you are feeling.
There are no words that can describe the depth and breadth of how sorry I am for what has occurred. An acceptable apology to all of you is impossible to write and convey. I will carry your words with me for the rest of my days."
First, everyone is ignoring the sacrifices that physicians make. Not to mention the demanding, difficult patients that he has to deal with.
The pain, trauma, and emotional destruction that all of you are feeling... Nassar should have said "he pain, trauma, and emotional destruction FOR WHAT I DID TO YOU." It is almost as if they are OUTLIERS for feeling that medical treatment was assault.
There are no words that can describe the depth and breadth of how sorry I am for what has occurred. Nassar should have said " ...what I intentionally did to you under the guise of medical treatments for my own perverse gratification."
An acceptable apology to all of you is impossible to write and convey. Because I am a physician and there should be NO apology. As a matter of fact, I did not even offer an apology.
-- Banterings
Banterings et al:
Do you think that there should be apologies expected from patients who attack or humiliate physicians or their staff for what is found later to be fully the responsibility of the patient him or herself? Take for a simple example, a not at all common but not totally rare scenario, where the patient behaves sexually provocative to the lone physician. Does this sexual provocation meet with a different conclusion of responsibility and freedom from responsibility simply because it is coming from a patient and not arising over a physician's behavior?
For example:
Acad Med. 1994 Oct;69(10):842-6.
Medical students' perceptions of patient-initiated sexual behavior.
Schulte HM1, Kay J.
Abstract
BACKGROUND:
Sexual behavior in the context of the doctor-patient relationship has potentially devastating effects on health care and the psychological well-being of patients.
METHOD:
To investigate the exposure of medical students to patient-initiated sexual behaviors (defined as any kind of sexual remarks or behaviors directed toward students by patients), 253 third- and fourth-year students and 1992 graduates of Wright State University School of Medicine were surveyed in the summer of 1992. The instrument used was a 16-item self-administered questionnaire, which solicited data on each respondent's age and gender as well as responses to patient-initiated sexual behavior, various aspects of the clinical settings in which such behavior occurred, and the effects of this behavior on the respondent's education and future practice.
RESULTS:
Of the 253 students and graduates surveyed, 155 (61%) responded (73 women and 82 men.) Fifty-two (71%) of the women and 24 (29%) of the men reported at least one instance of inappropriate sexual behavior by a patient. Frequently students had encountered inappropriate behavior more than once.
CONCLUSION:
Even assuming that all the nonrespondents had not experienced inappropriate sexual behavior, the proportion of students and graduates who did report such behavior is considerable. Understanding the extent and nature of patient-initiated sexual behavior experienced by physician trainees is hampered by differing definitions of inappropriate sexual behavior, subjective reporting, and variable perceptions of situations dependent on previous experience. Since patient-initiated sexual behavior can cause physicians to distance themselves from their patients and can put patients at risk for sexual exploitation, training in medical school is necessary to help students effectively manage such complex behavior.
and...
"A qualitative study of sexual harassment of female doctors by patients"
https://www.sciencedirect.com/science/article/pii/S027795369600384X
So.. should there be equal ethical and legal concerns about behavior on either side of the physican's desk or examining table? ..Maurice.
Ref: "At Wednesday, January 24, 2018 2:34:00 PM, Blogger Maurice Bernstein, M.D.said...", q.v.
Let's assume the criticism levied against the patient modesty thread also applies to this blog thread, viz. only those with negative experiences tend to respond. So, lets base the stats on the entire 253 students and graduates that were sent the survey.
There are still 20.5 % [52/253] of women and 9.5% [24/253] of men that reported inappropriate sexual behavior by a patient. This is still too high, especially when you consider that many positive results included more than one inappropriate behavior. It's a problem, even when inappropriate sexual behavior is somewhat subjective.
BJTNT
Even if half of the surveyed students/graduates are taking liberties with their definition of inappropriate behavior, the numbers are still too high and are indicative that patients also contribute to the sexualization of medicine.
It is also possible that the survey surfaces a piece of the communication gulf between patient and provider. Given the societal pressure on men to hide their embarrassment in opposite gender intimate medical encounters, one of the coping mechanisms is to use humor or bravado, either of which can easily come off as inappropriate behavior.
Maurice,
Exactly is inappropriate sexual behavior defined?
Is it a patient bullied into an exam making a statement to show displeasure?
Example: A patient told that he must submit to a female physician who is the only physician at the clinic because his employer requires a hernia exam and the patient says something like "You just wanted to feel me."
Is it the frightened patient trying to use humor to diffuse the situation?
Example: Male patient's first DRE and says "...at least you could buy me dinner and a movie first."
Is it a patient whose mental state is altered by drugs, alcohol, poisoning, or suffering mental illness?
Is tit a patient that says a genital exam feels like rape and the respondent finds it inappropriate because the patient is sexualizing a medical procedure?
Finally the one thing missed is that it was behavior witnessed by medical students. I would believe that having unnecessary people in the room creates more tension. Does the study look at if the patients were properly asked about student participation? PROBABLY NOT! Then one wonders why they respond in such a way.
As to equal ethical and legal concerns about behavior on either side of the physician's desk or examining table or a patient's apology, the physician should be held to a higher standard due to the power differential.
I do believe in personal responsibility and feel that patients should apologize if they were solely at fault. But many times the physician and/or their office is at fault when the context of the encounter is examined. For example, do you know why physician's offices now ask for a patient's driver's license/ID?
Most answer "we have to."
Here is the real answer; The FTC has passed down the Red Flags Rule mandating several requirements health care organizations must now do to "fight identity theft." The basic gist is the office must verify the patient is the same person that is on file. While copying the driver's license is NOT specifically required, it is a common way many offices are interpreting the requirements.
Most times there is a miscommunication issue. There is also the issue of trust. Has the entire physician's office worked to earn the trust of the patient? Many times people will just go along with what is being asked of them if they trust the person asking.
What physicians resent is being questioned. Before the internet, all that knowledge was hidden. Now physicians and/or their offices are being held MORE accountable by patients. The level of trust that they earned will determine how forgiving they were.
-- Banterings
Those contributing to this thread may be interested in the August 2007 thread on my blog: "The Sexually Seductive Patient: How Should Doctors React?"
http://bioethicsdiscussion.blogspot.com/2007/08/sexually-seductive-patient-how-should.html#comments
I wrote: "Psychologists explain these patients' behavior as expressions of transference--where psychologic unmet needs are attempted to be met by engaging physicians who seem to resemble and reflect critical persons in the patients' emotional life. Of concern is the issue of counter-transference--where the physician may respond to this situation in a manner to support the physician's unmet needs based on the physician's emotional life. This can lead to physicians responding to the seductive patient in a manner beyond the professional boundaries of sexual attention."
A number of interesting Comments.
If you were faced as a physician with such a patient, how would you respond? ..Maurice.
Maurice,
I feel that you are in denial to the culpability that medicine has. You may counter by saying you are presenting a counterpoint for ethical debate, but ethical debate does not justify denial of the truth. In one of the early 70's volumes you stated that although you have never experienced it with your patients, based on the EVIDENCE presented you could no longer attribute the things to outliers.
I have seen over the years that organizations are beginning to use lexicons that is specific to your blog. One such example is using dignity instead of modesty.
There are a whole lot more patients than there are providers. There is only one way this can end...
The only reason this has not changed faster is because providers are spending billions of dollars lobbying lawmakers. As providers are becoming employees of healthcare corporations, they are losing money and power.
Refusals to self police, and I don't mean requiring chaperones (that only creates more animosity), will continue to allow the Larry Nassars to proliferate and public opinion to shorten the leash.
-- Banterings
OK.. let's move on to a constructive component which could be looked upon as the opposite of this thread title. How about what behavior on both sides of the physician's desk and exam table would stop the "finger pointing" and yield a clasping of hands in a "together off we go" to solve the patient's diagnosis problem and to together attempt to achieve a cure? Does there have to be conflict? Is there some education that patients can be taught? Is there some education medical student and physicians can be taught? And with this teaching, understanding and following, the patient and doctor relationship would be what one would hope to be: one of understanding each other and working together to the same beneficent goal set by both parties. Is this education, through some impermeable wall of behaviors rarely possible to achieve? If so, how do we break down that "wall" and allow that "clasping of hands" to overcome the "pointing of fingers"? ..Maurice.
Maurice,
I will give you the solution, but healthcare providers will reject it and I argue, by nature of their training, unable to achieve it.
They must give up all control to the patient and seek to serve the patient. They must learn true humility.
Examples to follow include George Washington, Mahatma Gandhi,Jesus Christ, Mother Teresa, and the Dalai Lama. I think that Mahatma Gandhi is the best example of the ones listed. He quietly lead. He did not impose his will, he humbly lead. Despite having those around him with their own interests and trying to impose their wills ( Subhash Chandra Bose, Bhagat Singh), he served the people.
This was the seat of power for Jesus Christ. The best examples of this are him being baptized by John or washing the feet of His disciples to teach them how to serve thus imbuing them with the power to lead.
In my 3 part comment on Patient Modesty: Volume 84, and in much of my writings, I justify the reasons that patients need to be in charge. Since this is NOT being handed over to patients, we are taking it through things such as MOC, ACA, consumerism, Press Gainey surveys, etc.
Power is shifting slowly. Patients are conquerors in the land of healthcare. They will have to be treated like a subjugated peoples to prevent revolution and defeat of patient autonomy (a return to paternalism).
Now, if the industry were to change next week, and were to look like the predictions of Robert M. Veatch in his book: Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge NEJM review), then patients would NOT be conquerors, but rather elected leaders of healthcare.
Patients would not worry about being overthrown, but strive for a benevolence and justice (fairness) that their position elicits. Physicians would gain trust and status once again, and most importantly, HAPPINESS with their profession.
-- Banterings
Banterings, I am all in favor of a changed relationship between patient and the physician along with the medical system generally in order to bring a better environment toward diagnosis and treatment and hopefully cure, with all sides feeling comfortable with the process and each other.
The patient-doctor relationship is not just about the creation of diagnosis and cure but about the relationship itself where flaws in that relationship can be damaging to the very process leading to diagnosis and cure.
I am going to encourage first year medical student Surabhi to return and follow up on what Banterings has written. After all, it is in first year medical school where a doctor-to-be first interacts with real patients and where protocols of relationship with real patients is developed. ..Maurice.
Maurice,
You said:
...I am all in favor of a changed relationship between patient and the physician along with the medical system generally in order to bring a better environment toward diagnosis and treatment and hopefully cure, with all sides feeling comfortable with the process and each other.
I feel that you are having troubles accepting my solution let alone the rest of the profession who may not be as open minded as you. You have NOT even entertained my solution as a possibility.
Ask your students their thoughts on my proposal. They have not been indoctrinated into the system (fully) yet.
As Robert Veatch writes, there is only one logical outcome... We are going to get there. We are moving towards it now. We are going to enter the hospitals as a triumphed conquerors and healthcare will be subjugated.
My solution actually gives physicians ALL the power: they will voluntary relinquish ALL power. They will have preempted the power struggle and decided the outcome. They can claim victory. This is what Christ and Gandhi did.
Instead, the profession thinks that the genie can be put back in the bottle. They think that we can go back to paternalism.
We are already winning the war as fewer and fewer MDs are in upper management of healthcare corporations. Unfortunately corporations are more beholden to shareholders than the public, but they are much easier to regulate.
All my statements from when I started posting here that you have denied the validity of, I have demonstrated to be true. The most recent work, When Treatment Becomes Trauma unifies what I have stated all along.
The truth cannot be denied, and it will be exposed as it has been. When the numbers are analyzed, the invasive, intimate CA screenings that were thrust upon patients were found to cause more harm than good. As the one review found about PEs, they tend to be more ritual than science.
-- Banterings
I am all in favor of Veatcb and Banterings providing us their insight into the medical world of today. I am all in favor of patient autonomy and no return to the times of physician paternalism. This is in contrast to the reviewer of the Veatch book who wrote "Veatch unintentionally helps to sharpen our appreciation for how medicine necessarily must accommodate more enlightened forms of paternalism than those that prevailed in the past." I disagree with the reviewer's goal of a more "enlightened form of paternalism" by the medical profession.
All I want is for doctor and patient to work together toward goals set by the patient and practical options outlined by the physician.
You see, education is part of patient-doctor relationship and education should go in both directions but with the patient making their final decisions.
Yes, the healthcare system must be changed to provide progressively more input by the patient population and less restrictions set by administers of healthcare.
This ideal world in medicine is yet to be completed ..Maurice.
Maurice,
Your statement "...practical options outlined by the physician" assumes that the physician is infallible. In this scenario assumes ONLY the physician selects the choices that the patient gets to pick from. This would work IF the physician was infallible.
Time and time again we have seen that mistakes were made (and others blamed).
Augusto and Michaela Odone, were two parents in a relentless search for a cure for their son Lorenzo's adrenoleukodystrophy and found a cure when the medical establishment could not.
Brian Persaud refused a trauma (neurological) rectal exam (a choice NOT offered to patients). When the science was reviewed, the DRE in trauma settings has low sensitivity and does not change subsequent management and was removed from the ATLS in 2009.
Many patients skipped
birth control because they were forced to endure unnecessary, ritualistic pelvic exams.
Patients are often forced to endure unnecessary urinary catheterization which are often done for the convenience of the nursing staff.
I can go on...
I think a better solution would to model medicine after the financial industry. No longer do we have stockbrokers, we have financial advisors. The financial advisor makes recommendations and will advise on the client's recommendations when the advisor's are rejected. Ultimately, the financial advisor follows the wishes of the client.
The financial industry has suffered a loss of trust from many debacles. Financial advisors are the new paradigm as previous individuals are consolidated as employees of big financial corporations. (I see a pattern here...)
-- Banterings
Banterings, I am all in favor of identifying the doctor of medicine as a "medical adviser" in the context of medical decision making which is finally decided by the patient or surrogate. There are, however, some legal or ethical issues related to the patient's final decision. For example, physician directly involved in patient requested suicide. ..Maurice.
Maurice,
That is a great example that I should have included with BC, DRE, and catheterization.
While I would NOT expect the physician would recommend this option, NOR would I expect the physician to "pull the trigger," this may be something that the patient requests.
I fully support one's right to die with dignity and the ethics of this can be found with the largest and oldest right to die organization.
Note: The Hemlock Society was organized in 1980, split into two separate organizations that essentially share
the same belief in death with dignity, but each of these two organizations has
a different focus. These two groups are :
Compassion and Choices focuses on legislative change.
Final Exit Network focuses on compassionate support and death with dignity education in all states.
-- Banterings
Banterings, et al: I want to go back to the original title of this thread "Difficult Patient vs Difficult Doctor" and tell you something that I have learned as being over the years chairman of two hospital ethics committee and currently a regular member of one. My experience is that of active participation in a hospital ethics committee "consultation" with family and physicians (often the patient is absent because of critical condition or gross lack of decisional capacity and the family or other surrogate speaks for the patient.
We don't find either party, considered "stakeholders" either "difficult" or need to point fingers. They provide worthy arguments on both sides or often they are in general agreement but unsure of the ethics or law. And our ethics committee's role is to educate both parties and mediate any disagreements. And, over the years, I have seen that it works!
What I am getting at is that what seems like a "difficult" party in the patient and doctor relationship is not necessarily one or both of the parties. And maybe the "difficulty" is awaiting what is needed to resolve conflicts is professional education and mediation directed to both parties.
And like what often does happen at the end of a hospital ethics committee meeting is the stakeholders (family and medical staff) leaving shaking hands and no longer pointing fingers. ..Maurice.
Maurice,
Ethics Committees don't always work. Where were they for M.C. (Carolina Infant’s Mistaken Sex Assignment Surgery More Than a Case of Malpractice)?
Generally they do work because the stakes are so high and something, anything, needs to be done. In the case of M.C., medicine had already made up its mind incorrectly. The intersexed community had been trying to tell medicine this for years, yet it fell on deaf ears.
This lead the United Nations to declare that the treatment of intersexed individuals in industrialized countries amounts to torture. Also see Ending Forced 'Genital-Normalizing' Surgeries and Medically Unnecessary Surgeries on Intersex Children in the US.
The problem is that how day an ordinary person tell a learned doctor what is correct? It takes cases like that in South Carolina to usher in change, and that change makes the leash shorter and tighter on physicians. My Gandhi solution is the solution that would restore power and respect to physicians.
Patients don't care if they are elected officials or conquerors, we are simply safe.
Mediation such as ethics committees is also absent on the GP level. Too often the physician fires the patient or the patient leaves. Both are unhappy and can be vindictive. If healthcare truly served the patient, then things would never get that far. Patient input in healthcare has been absent far too long. Healthcare is being bent to meet society's expectations, not what the physician thinks is best.
I like the direction we are going. We just need to move faster.
-- Banterings
To Banterings & Dr. Bernstein,
I read through the discussion so far, and I find that I agree with many points you both have made.
First, I agree with the notion that paternalism and physician infallibility are relics of the past. An ideal model of medicine would involve a physician making an objective recommendation to a patient (utilizing that physician's medical experience and education), and the patient having the autonomy to decide the course of action. Eric Topol's book "The Patient Will See You Now" describes The Gutenberg Movement, in which the invention of the printing press took learning out of the hands of priests and allowed people to learn for themselves (and on their own terms) through books. In a similar way, technological tools will allow patient's to manage their own care to a certain degree - without blind deferral to a physician. I think Bantering's description of the role of a financial adviser is an apt analogy.
However, I think Dr. Bernstein's point is that collaboration (rather than consultation/service to patient) is a vital element to healthcare. While the patient is the greatest stakeholder in medicine (as their health is on the line), physicians also perceive themselves as a stakeholder and team-member in the patient's care. Some physicians may take control as a way to demonstrate power, but I think most physicians are simple invested in the patient's outcome out of empathy. Blind service to a patient seems too callous of a model to me - and while it works in a financial setting, I think medical care necessitates a greater sense of intimacy and involvement. Ultimately, I think this is what differentiates medicine from any other service industry.
Is it wrong for physicians to take too much control in their patient's management? Yes, absolutely. But I think in many cases it is done out of a deep concern for the patient's wellbeing and a desire to help. This may reflect my naivety on the issue, but I can say that I have met a lot of physicians that describe a need to be an advocate for their patients.
I appreciate Surabhi's view on physician's "concern" for the patient rather than their own desire to demonstrate "power".
There is one behavior of physicians which I think has to do with the physician being a "medical adviser in the context of medical decision making" (my words from Feb. 12) which to some may represent a return to "paternalistic behavior" but to others part of being a medical educator for the patient to make the final decision and that behavior is "the nudge".
And, indeed, I have a thread on the subject which my visitors here can review but if commenting relative to "difficult doctors" better to comment about the "nudge" on our thread here.
Will those considering the professional "nudge" point to it as a beneficent act or something to stand in the way of the best in doctor-patient relationships? ..Maurice.
I found another thread on my blog which supplements the discussion already in progress here. It is titled "As a Patient: I Am My Own Doctor. Trust Me"
The issue is should the patient be given more power in his or her own medical management than what is available to the patient currently? For example, provide a greater number or types of "over-the-counter" drugs which would not require a physician's prescription or even a visit to a physician. Would this possibility contribute to making the "difficult" in description of physician (or indeed the medical system) by a patient less likely.
Are there other approaches to increase patient autonomy while still providing an active and safe medical system? ..Maurice.
First what may be a dumb question. Do doctors actually put "difficult patient" in the records? I sure hope not given today's electronic records are seemingly accessible by more people than not.
This topic is a bit hard to follow but I will add my two cents. I try to not self diagnose. The doctor went to medical school and through a residency program. I didn't. If there are options I want to know what they are, but then I also want to know what the doctor recommends. I prefer he not be subtle in the nudging. That kind of paternalism is fine with me. I will almost always go along with whatever the doctor says is the best course of action. We are not equal partners in that regard in that he has expertise that I don't. Where I push back is generally only with minor things like refusing sedation or the presence of his female scribe.
Biker, you wrote "Do doctors actually put "difficult patient" in the records? I hope not with only these two words. They say something ambiguous: either the patient's behavior is a challenge to the doctor or the patient's symptoms and illness is a diagnostic challenge. In terms of patient behavior, the desires or concerns of the patient as understood by the physician (and acknowledged as such) is of importance to document for future constructive interaction with the patient. What ever is written in the chart should be realistically specified so future issues can be resolved to the benefit of the patient.
But, unfortunately, bad descriptions or inaccuracies about the patient or the interaction with the patient are written in the chart. I found two of my blog threads which discuss the subject:
"Dark side of Medicine: Writing Lies" and
"The Ethics of Blacklisting.."
that might be of interest to review my many visitor comments on this subject.
..Maurice.
Maurice,
As commented in the thread "As a Patient: I Am My Own Doctor. Trust Me," the wealthy already have private doctors. I suspect that you have probably not experienced this being that you are not directly treating patients, but I can tell you that VIP patient status is alive and well. Whether it be the families that build new halls for institutions of higher learning OR the congressman (or donors of the congressman) who votes for the bill that benefits the for profit system, the golf buddy/fraternity brother of the member of the healthcare system C suite, these people are treated much different.
I can tell you that if a congressman's nephew was undergoing surgery by Twana Sparks, there would be NO genital exam. I will tell you that I have even leveraged my position to be treated as a VIP with a surgeon. I am sure that 3rd and 4th students have encountered VIPs. They MAY be asked, but WILL be asked for permission for students to participate. The attending will keep students on a very tight leash, the students will always gladly use them as a professional reference. If the attending even allows the request of student participation for intimate procedures, it will not be pushed. Students may handle more menial tasks to make the VIP feel well attended to.
Indeed, controversy arose of our Governor Casey's double organ transplant. It was widely known that his VIP status expedited his surgery. The real way that his VIP status influenced his case was by having his Dx to elevated to a need of a double double transplant thus skipping all other single need patients. (See: additional info.)
there are (excessively) more lawyers per capita than physicians. This is how the common man is currently levelling the playing field. It is furthered in patients' favor by politicians seeking votes willing to trade the power of physicians for votes. The Affordable Care Act comes to mind.
Overseas pharmacies have also taken away physicians' power. The main reason that the Federal Government opposes it is the lobbying by big pharma over loss of domestic revenues. Even politicians are ready to allow overseas pharmacies.
Patients have travelled to foreign countries not only for savings, but also so that one can buy their own physician more cheaply abroad than home. Foreign countries are more than willing to take advantages of medical tourism and the billions of dollars that it offers.
-- Banterings
Interesting comments Banterings. You are right no classic VIP (which you describe) now since for the past 14 years I have been also a physician in a "free clinic" for the poor and non-citizens.. however, to me and hopefully to the other physicians who participate there they continue to be considered as a patient nothing other than "Very Important Person". Really. All students should look to their patients and patients to be as "very important" since the outcome of the relationship tells beyond the pathology outcome but also the outcome of the doctor-patient relationship itself. ..Maurice.
Maurice,
I agree that physicians should view each patient as a VIP, in fact I believe that most ALL physicians view their patients this way.
What the VIP status gets them more consideration. VIPs don't have to fight for same gender care, they simply request it if not already provided. It also gets the physician to acquiesce to patient requests; antibiotics being the most common example. Finally they get the physicians to acquiesce to foregoing certain things that they may insist on, such as (the recent example here) as a genital exam with a full body skin exam.
I mentioned a friend up north who was in patient for 5 days for IV antibiotic infusion: he laments that he should have been more forceful in demanding that the physician write an Rx for home infusion. There was no reason that a home health nurse could not have done that.
What we are seeing is that the standard of care is to OFFER certain procedures (there is Federal law supporting this), and NOT demanding that they be preformed. Again, I offer the example of the recent example of a genital exam with a full body skin exam.
-- Banterings
Another interesting aspect of the doctor and patient pointing fingers at each other as "difficult" is the mechanism of how a doctor-patient relationship is terminated. A patient can stop returning for visits with that physician with no legally defined consequences. On the other hand, the physician legally cannot abandon a patient and must at least maintain care of the patient until stable and refer the patient to another physician.. well, at least in the state of California.
i got a bunch of comments from visitors when I put up the thread in 2004 "Breaking the Doctor-Patient Relationship: The Suing Patient".
Another issue is at what point does the "difficult" party on one side remove themselves from the "difficult" party on th other side? If a patient leaves a doctor for whatever reason, should the patient be responsible for the transfer of care? ..Maurice.
Maurice,
Because so many people are on maintenance medications that can disrupt not only the patient's life, but society as well, the onus has to be on the physician for the continuum of care. Furthermore, the patient is expected to follow the orders of the physician yet the physician does not have to do what the patient says, but can only stop doing something the patient objects to.
With the power so one sided, obvious the more powerful party has the responsibility
-- Banterings
I don't want to be bias; I know that both parties (patient and doctor) have the responsibility to the continuity of a good relationship between them. However, I think the main burden falls on the doctor due to many reasons:
Firstly, the patient might not have the sufficient understanding of treatment procedures that qualifies him/her to estimate the complications, risks, instructions and uncomfortable steps of treatment. Whereas, the professionalism owned by the doctor, makes him/her aware of the psychological and physical pressure that the patient undergoes, and lead this patient to be rude or in a bad mood.
Secondly, the health issues of the patient can lead him/her to be impatient, anxious, and irritated. This situation will make the patient seeking for attention, time and sympathy from the doctor. However, if the patient couldn’t find these aspects in his doctor's behaviour, then he/she will transform to a DIFFICULT PATIENT.
In my opinion, the misbehaviour of the patient is a reverse reaction to his/her failed hopes in getting someone trusty, represented by the doctor, to reassure the patient, minimise his/her fear and uncomfortable feelings. Therefore, when the doctor has ignored the patient or behaved badly with him/her. This doctor will address under a DIFFICULT DOCTOR.
The establishment of a good relationship between the doctor and the patient is based on mutual respect and cooperation between these two parties. The doctor plays an important role in conveying the instruction clearly and empathically. The patient, on the other hand, should obey the doctor's instruction and follow regime as provided by the doctor. These things will minimse the case of a DIFFICULT patient or DIFFICULT doctor. But still, most of the burden will be on the doctor.
Often the "difficult" developing in the relationship is due to lack of time, in this era of medical practice, provided for that initial relationship to develop. Time is required for both parties to "get to know" each other. And with time limited by the way medical care is practiced and paid for in this medical economic era, time to communicate and collaborate is often not a considered or available factor. ..Maurice.
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